J Korean Soc Surg Hand.  2016 Sep;21(3):122-130. 10.12790/jkssh.2016.21.3.122.

Non-Structural Cancellous Bone Graft and Headless Compression Screw Fixation for Treatment of Scaphoid Waist Nonunion

• Lee JK
• Hong IT
• Kim U
• Kim J
• Han SH

• KMID: 2353816
• DOI: http://doi.org/10.12790/jkssh.2016.21.3.122

Abstract

PURPOSE
The authors performed an autologous cancellous bone graft from the iliac crest and headless compression screw fixation for the treatment of Mack-Lichtman type II scaphoid waist nonunion. The purpose of this study was to determine whether this procedure was effective in achieving bony union and restoration of alignment.
METHODS
We retrospectively reviewed medical records and radiographs of 30 patients who underwent a cancellous bone graft and headless compression screw fixation for scaphoid waist nonunion. There 28 men and 2 women with a mean age of 32.8 year-old (range, 21-63 year-old). The mean time to surgery from initial injury was 10 months (range, 3-25 months) and the average follow-up duration was 37.5 months (range, 15-52 months). The authors analyzed bony union, lateral intrascaphoid angle (LISA), scapholunate angle (SLA), radiolunate angle (RLA), and scaphoid length in radiographs and evaluated the modified Mayo wrist score (MMWS) as a functional outcome.
RESULTS
Bony union was achieved in all cases. In lateral plain X-ray, preoperative anatomic alignment including LISA, SLA, RLA, and scaphoid length was recovered at immediate postoperative measurement. Those alignment restoration was likely to maintain in final follow-up in despite of statistical difference. The wrist motion and the MMWS improved significantly at the last follow-up.
CONCLUSION
A non-structural autologous cancellous bone graft from the iliac crest and headless screw fixation provided reliable results and can be one of the effective treatment options for patients with symptomatic Mack-Lichtman type II nonunion in the middle one-third of the scaphoid.

Keyword

Scaphoid; Nonunion; Cancellous bone graft; Headless compression screw

MeSH Terms

Female
Follow-Up Studies
Humans
Male
Medical Records
Retrospective Studies
Transplants*
Wrist

Figure

• 

  Fig. 1. Surgical procedures. (A) Sclerotic border of the nonunion site is removed by a burr and curette. (B) Preparation of biconcave cavity with healthy cancellous wall. (C) Packing of cancellous bone around the guide pin for the headless compression screw. (D) Headless compression screw fixation. (E) Additional tight cancellous bone packing into the surrounding defect.

• 

  Fig. 2. Results of radiologic measurements at preoperative (Pre), immediate postoperative (Post) and final follow-up (Final). Repeated measurement analysis of variance, significance with less than p=0.05. (A) Lateral intrascaphoid angle, LISA (standard deviation) (B) Scapholunate angle, SLA (standard deviation). (C) Radiolunate angel, RLA (standard deviation). (D) Scaphoid length (standard deviation).

• 

  Fig. 3. Radiographs in a 63-year-old male patient at injury and 1 year after surgery. (A, B) Preoperative radiographs showing the measurement of the scaphoid length and LISA. (C, D) Postoperative radiographs showing the measurement of the scaphoid length and LISA after the surgery, when the bony union is achieved. The length is improved from 2.5 cm to 2.8 cm and the LISA is decreased from 44° to 37°. LISA, lateral intrascaphoid angle.

Reference

1. Buijze GA, Ochtman L, Ring D. Management of scaphoid nonunion. J Hand Surg Am. 2012; 37:1095–100.

2. Cooney WP 3rd, Dobyns JH, Linscheid RL. Nonunion of the scaphoid: analysis of the results from bone grafting. J Hand Surg Am. 1980; 5:343–54.

3. Eddeland A, Eiken O, Hellgren E, Ohlsson NM. Fractures of the scaphoid. Scand J Plast Reconstr Surg. 1975; 9:234–9.

4. Osterman AL, Mikulics M. Scaphoid nonunion. Hand Clin. 1988; 4:437–55.

5. Pao VS, Chang J. Scaphoid nonunion: diagnosis and treatment. Plast Reconstr Surg. 2003; 112:1666–76.

6. Mack GR, Bosse MJ, Gelberman RH, Yu E. The natural history of scaphoid non-union. J Bone Joint Surg Am. 1984; 66:504–9.

7. Mack GR, Kelly JP, Lichtman DM. Scaphoid non-union. Lichtman DM, Alexander AH, editors. The wrist and its disorders. 2nd ed.Philadelphia: Saunders;1997. p. 234–67.

8. Gabl M, Reinhart C, Lutz M, et al. Vascularized bone graft from the iliac crest for the treatment of nonunion of the proximal part of the scaphoid with an avascular fragment. J Bone Joint Surg Am. 1999; 81:1414–28.

9. Munk B, Larsen CF. Bone grafting the scaphoid nonunion: a systematic review of 147 publications including 5,246 cases of scaphoid nonunion. Acta Orthop Scand. 2004; 75:618–29.

10. Markiewitz AD, Stern PJ. Current perspectives in the management of scaphoid nonunions. Instr Course Lect. 2005; 54:99–113.

11. Ramamurthy C, Cutler L, Nuttall D, Simison AJ, Trail IA, Stanley JK. The factors affecting outcome after non-vascular bone grafting and internal fixation for nonunion of the scaphoid. J Bone Joint Surg Br. 2007; 89:627–32.

12. Herbert TJ, Fisher WE. Management of the fractured scaphoid using a new bone screw. J Bone Joint Surg Br. 1984; 66:114–23.

13. Cohen MS, Jupiter JB, Fallahi K, Shukla SK. Scaphoid waist nonunion with humpback deformity treated without structural bone graft. J Hand Surg Am. 2013; 38:701–5.

14. Gereli A, Nalbantoglu U, Sener IU, Kocaoglu B, Turkmen M. Comparison of headless screws used in the treatment of proximal nonunion of scaphoid bone. Int Orthop. 2011; 35:1031–5.

15. Lee JH, Kim MS. Pure Cancellous Iliac Bone grafting for the Treatment of Scaphoid Waist Nonunions with Humpback Deformity. J Korean Soc Surg Hand. 2014; 19:36–43.

16. Park HY, Yoon JO, Jeon IH, Chung HW, Kim JS. A comparison of the rates of union after cancellous iliac crest bone graft and Kirschner-wire fixation in the treatment of stable and unstable scaphoid nonunion. Bone Joint J. 2013; 95B:809–14.

17. Steinmann SP, Adams JE. Scaphoid fractures and nonunions: diagnosis and treatment. J Orthop Sci. 2006; 11:424–31.

18. Watanabe K. Analysis of carpal malalignment caused by scaphoid nonunion and evaluation of corrective bone graft on carpal alignment. J Hand Surg Am. 2011; 36:10–6.

19. Amadio PC, Berquist TH, Smith DK, Ilstrup DM, Cooney WP 3rd, Linscheid RL. Scaphoid malunion. J Hand Surg Am. 1989; 14:679–87.

20. Kawamura K, Chung KC. Treatment of scaphoid fractures and nonunions. J Hand Surg Am. 2008; 33:988–97.

21. Tambe AD, Cutler L, Murali SR, Trail IA, Stanley JK. In scaphoid non-union, does the source of graft affect outcome? Iliac crest versus distal end of radius bone graft. J Hand Surg Br. 2006; 31:47–51.

22. Kirkham SG, Millar MJ. Cancellous bone graft and Kirschner wire fixation as a treatment for cavitary-type scaphoid nonunions exhibiting DISI. Hand (N Y). 2012; 7:86–93.

23. Watson HK, Pitts EC, Ashmead D 4th, Makhlouf MV, Kauer J. Dorsal approach to scaphoid nonunion. J Hand Surg Am. 1993; 18:359–65.

24. Nagle DJ. Scaphoid nonunion: treatment with cancellous bone graft and Kirschner-wire fixation. Hand Clin. 2001; 17:625–9.

25. Myeroff C, Archdeacon M. Autogenous bone graft: donor sites and techniques. J Bone Joint Surg Am. 2011; 93:2227–36.